Anxiety Disorders Prof Anatoly Kreinin Maale Carmel Mental

Anxiety Disorders Prof. Anatoly Kreinin Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 1

Определение понятия Тревога Ø Ø Это душевное состояние , характеризующееся психологическими, физиологическими и когнитивными изменениями, вызывающие у того, кто это состояние переживает, ощущение угрозы. Физиологический компонент – пальпитации, пот, удушье, головокружение, расплывчатое зрение, учащенные мочеиспускание и дефекация, Психологический компонент – неприятное чувство дисфории, ощущение дискомфорта, сниженное настроение Когниция – мысли о том, что должно случиться что-то неприятьное, страшное

Не всякая Тревога патологична Патологическая Тревога Ø Ø Существует и при отсутствии стрессора Выраженность реакции не соответствует триггеру Продолжается и после исчезновения триггера Нарушается функционирование Нормальная Тревога Ø Ø Есть стрессор Выраженность реакция соответствует триггеру Проходит при отсутствии триггера Нет нарушения функционирования Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 4

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Что хорошего в Тревоге? Ø Ø Ø Готовность – мы легко реагируем на угрозы, знакомые нам в процессе тысячелетней эволюции (кровь, змея, буря, наводнение, землятресение…) Нет тревоги на цветы, листья, лужу. . Нет первичной тревоги на современные угрозы – ружье, машина, кирпич…

Benefits of anxiety Закон Давидсона: Функционирование улучшается с усилением тревоги до определенного уровня, после которого начинает снижаться Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 8

General considerations for anxiety disorders Ø Ø Often have an early onset- teens or early twenties Show 2: 1 female predominance Have a waxing and waning course over lifetime Similar to major depression and chronic diseases such as diabetes in functional impairment and decreased quality of life Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Primary versus Secondary Anxiety may be due to one of the primary anxiety disorders OR secondary to substance abuse (Substance. Induced Anxiety Disorder), a medical condition (Anxiety Disorder Due to a General Medical Condition), another psychiatric condition, or psychosocial stressors (Adjustment Disorder with Anxiety) The differential diagnosis of anxiety. Psychiatric and Medical disorders. Psychiatr Clin North Am 1985 Mar; 8(1): 3 -23 Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Comorbid diagnoses v Once an anxiety disorder is diagnoses it is critical to screen for other psychiatric diagnoses since it is very common for other diagnoses to be present and this can impact both treatment and prognosis. What characteristics of primary anxiety disorders predict subsequent major depressive disorder. J Clin Psychiatry 2004 May; 65(5): 618 -25 Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Anxiety disorders Ø Ø Ø Specific phobia Social anxiety disorder (SAD) Panic disorder (PD) Agoraphobia Generalized anxiety disorder (GAD) Anxiety Disorder due to a General Medical Condition Ø Substance-Induced Anxiety Disorder Ø Anxiety Disorder NOS Ø Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Биологическая база Тревоги ØЗамешанные структуры: Ø Ø Логбные доли Лимьическая система Ø Ø Ø Гипоталамус, Гипокампус Амигдала Ствол мога Гипофиз Adrenal Axis Симпатическая система Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 14

Fight or Flight ØФизиологическая реакция на стресс ØАдаптируется с помощью гипоталамуса и других мозговоых структур ØПозволяет адекватно реагировать на угрозу ØСуществует у всех живых организмов, в этом отношении мы - животные Ø « Симатическая реакция» Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 21

Что происходи при реакции симпатической системы? ØПроисходит с помошью адреналина и норадреналина ØУсиливает частоту и силу сердечных сокращений ØУскоряется частота дыхания ØУсиливается потоотделение Ø Усиливается утилизация глюкозы ØПерераспределение крови к мышцам ØУвеличение напряжения в мышцах ØУлучшение свёртываемости крови Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 23

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A Developmental Hierarchy of Anxiety Ø Ø Ø Superego anxiety Castration anxiety Fear of loss of love Separation anxiety (fear of the loss of the object—Kleinian depressive anxiety) Persecutory anxiety (Klein) Disintegration anxiety (Kohut) Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 27

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А. Барак: "В основе любой патологии лежит чрезмерное и необоснованное обобщение» Депрессия Мания, эйфория Паранойя Паника Сниженое настроение Радость Подозрение Тревога Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 34

Pathological Anxiety ØКак часть патологической адаптивной реакции ØЧасть другого патологического расстройства ØПервичная патологическая реакция Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 36

Primary Anxiety Disorders Нефобические тревожные реакции: ØGENERAILIZED ANXIETY DISORDER Фобические тревожные реакии: Ø SIMPLE PHOBIA Ø SOCIAL PHOBIA Ø PANIC DISORDER Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 38

Эпидемиология ØВ большинстве своем женщины страдают чаще мужчин, в основном в возрасте 16 -40 лет ØСоциофобия в 2 раза чаще у женщин, но мужчины ищут помощь чаще. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 40

Prevalence of Anxiety Disorders Lifetime Prevalence (%) (life time prevalence %) 30 Lifetime Prevalence 22. 5 15 7. 5 0 Any Anxiety Disorder Social Anxiety Disorder PTSD Generalized Anxiety Disorder Panic Disorder Kessler et al. Arch Gen Psychiatry. 1995; 52: 1048. Kessler et al. Arch Gen Psychiatry. 1994; 51: 8. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 41

Genetic Epidemiology of Anxiety Disorders Ø There is significant familial aggregation for PD, GAD, OCD and phobias Ø Twin studies found heritability of 0. 43 for panic disorder and 0. 32 for GAD. Hetteman J. et al. A Review and Meta-Analysis of the Genetic Epidemiology of Anxiety disorders. Am J Psychiatry 2001; 158: 1568 -1575 Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Anxiety Disorders “The anxiety must be out of proportion to the actual danger or threat in the situation” This chapter no longer includes OCD and PTSD DSM 5 creates new chapters for OCD and PTSD Chapter is arranged developmentally. Sequenced by age of onset Now includes Separation Anxiety and Selective Mutism

Anxiety Disorders Agoraphobia , Specific Phobia, and Social Anxiety Disorder Changes in criteria : Clients over 18 do not have to recognize that their anxiety is excessive or unreasonable Duration of 6 months or longer is required for all ages

Specific Phobia Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

SPECIFIC PHOBIA Ø Ø Ø Animal Type Natural Environment Type (e. g. , heights, storms, water) Blood-Injection-Injury Type Situational Type (e. g. , airplanes, elevators, enclosed places) Other Type Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 47

Specific Phobia Ø Marked or persistent fear (>6 months) that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation Ø Anxiety must be out of proportion to the actual danger or situation Ø It interferes significantly with the persons routine or function Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

SPECIFIC PHOBIA Ø Ø Ø 94 בשאר הזמן תפקוד נורמאלי המנעות מאפשרת חיים נורמאליים שכיחות גבוהה –עד %02 מהאוכלוסייה בד"כ לא פונים לטיפול בד"כ ללא סיבוכים טיפול ב CBT יעיל מאוד , לא זקוקים לתרופות. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

SOCIAL PHOBIA Ø Ø 05 בדומה לפוביה פשוטה אך כאן הפחד חסר הגיון מאינטראקציה חברתית , ומכאן: Ø יותר פגיעה תפקודית Ø יותר אירועי חשיפה Ø ההימנעות לא מאפשרת חיים נורמליים התוכן של החרדה -החשש מהשפלה , ביזוי , כישלון וכו' Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

SAD epidemiology Ø 7% of general population Ø Age of onset teens; more common in women. Stein found half of SAD patients had onset of sx by age 13 and 90% by age 23. Ø Causes significant disability Ø Increased depressive disorders Incidence of social anxiety disorders and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry 2007 Mar(4): 221 -232 Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

( ? ? אבחנה יותר בעייתית )הפרעת אישיות : שני סוגים LIMITED Ø PERVASIVE Ø Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa Ø Ø 52

Social Anxiety Disorder treatment Ø Social skills training, behavior therapy, cognitive therapy Ø Medication – SSRIs, SNRIs, MAOIs, benzodiazepines, gabapentin Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

: סיבוכים דיכאון Ø שימוש בחומרים ממכרים Ø Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa Ø 58

PANIC DISORDER התקף אימה , חרדה בעוצמה קיצונית ( מופיע ספונטאנית )לפחות בתחילת המחלה הכללת אירועים ANTICIPATION ANXIETY - חרדה מטרימה התפתחות המנעות – אגורפוביה Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa Ø Ø Ø 59

Panic Disorder Ø Recurrent unexpected panic attacks and for a one month period or more of: Ø Persistent worry about having additional attacks Ø Worry about the implications of the attacks Ø Significant change in behavior because of the attacks Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

A Panic Attack is: v v v v A discrete period of intense fear in which 4 of the following Symptoms abruptly develop and peak within 10 minutes: Palpitations or rapid v Chills or heat sensations heart rate v Paresthesias Sweating v Feeling dizzy or faint Trembling or shaking v Derealization or Shortness of breath depersonalization Feeling of choking v Fear of losing control or going crazy Chest pain or discomfort v Fear of dying Nausea Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Panic disorder epidemiology Ø Ø 2 -3% of general population; 5 -10% of primary care patients. Onset in teens or early 20’s Female: male 2 -3: 1 Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Things to keep in mind Ø Ø A panic attack ≠ panic disorder Panic disorder often has a waxing and waning course Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

With Agoraphobia פחד או המנעות להיות במקומות או במצבים בהם יש . קושי לברוח או לקבל עזרה Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa Ø 64

סיבוכים: Ø 56 Ø דיכאון עד %05 Ø תלות בחומרים ממכרים - אלכוהול , תרופות הרגעה Ø פגיעה תפקודית קשה חשוב לברר: Ø הרגלי קפאין Ø מחלות גופניות – תירוטוקסיות , פאוכרומוציטומה, , MVP Ø טיפול: שילוב של טיפול CBT ותרופות: Ø נוגדי דיכאון Ø נוגדי חרדה לשלב הראשון Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Panic Disorder Comorbidity Ø Ø 50 -60% have lifetime major depression Ø One third have current depression 20 -25% have history substance dependence Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Panic Disorder Etiology Ø Ø Ø Drug/Alcohol Genetics Social learning Cognitive theories Neurobiology/conditioned fear Psychosocial stressors Ø Prior separation anxiety Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Treatment Ø Ø See 70% or better treatment response Education, reassurance, elimination of caffeine, alcohol, drugs, OTC stimulants Cognitive-behavioral therapy Medications – SSRIs, venlafaxine, tricyclics, MAOIs, benzodiazepines, valproate, gabapentin Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Agoraphobia Ø Marked fear or anxiety for more than 6 months about two or more of the following 5 situations: Ø Using public transportation Ø Being in open spaces Ø Being in enclosed spaces Ø Standing in line or being in a crowd Ø Being outside of the home alone Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Agoraphobia Ø Ø Ø The individual fears or avoids these situations because escape might be difficult or help might not be available The agoraphobic situations almost always provoke anxiety Anxiety is out of proportion to the actual threat posed by the situation The agoraphobic situations are avoided or endured with intense anxiety The avoidance, fear or anxiety significantly interferes with their routine or function Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Prevalence Ø Ø Ø 2% of the population Females to males: 2: 1 Mean onset is 17 years 30% of persons with agoraphobia have panic attacks or panic disorder Confers higher risk of other anxiety disorders, depressive and substance-use disorders Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Generalized Anxiety Disorder Ø Ø Ø Excessive worry more days than not for at least 6 months about a number of events and they find it difficult to control the worry. 3 or more of the following symptoms: Ø Restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance Causes significant distress or impairment Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

GAD Comorbidity Ø Ø Ø 90% have at least one other lifetime Axis I Disorder 66% have another current Axis I disorder Worse prognosis over 5 years than panic disorder Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Long-Term Treatment Of GAD Ø Ø Ø Need to treat long-term Full relapse in approximately 25% of patients 1 month after stopping treatment 60%-80% relapse within 1 st year after stopping treatment Hales et al. J Clin Psychiatry. 1997; 58(suppl 3): 76. Rickels et al. J Clin Psychopharmacol. 1990; 10(3 suppl): 101 S. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 75

ANXIETY PATHOLOGICAL ANXIETY ADJUSTMENT DISORDER NORMAL ANXIETY SECONDARY ANXIETY PRIMARY ANXIETY DISORDER PHOBIC SIMPLE PHOBIA NON PHOBIC GAD SOCIAL PHOBIA PANIC DISORDER AGORAPHOBIA Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 76

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Pharmacotherapy for Anxiety Disorders Antidepressants Serotonin Selective Reuptake Inhibitors (SSRIs) Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Atypical Antidepressants Tricyclic Antidepressants (TCAs) Monoamine Oxidase Inhibitors (MAOIs) Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 78

Benzodiazepines Other Agents Azaspirones Beta blockers Anticonvulsants Other strategies Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 79

Discontinuation of Treatment for Anxiety Disorders Ø Withdrawal/rebound more common with Bzd than other anxiolytic treatment Ø Relapse: a significant problem across treatments. Many patients require maintenance therapy Ø Bzd abuse is rare in non-predisposed individuals Ø Clinical decision: balance comfort/compliance/ comorbidity during maintenance treatment with discontinuationassociated difficulties Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 80

Strategies for Anxiolytic Discontinuation Ø Ø Slow taper Switch to longer-acting agent for taper Cognitive-Behavioral therapy Adjunctive Ø Antidepressant Ø Anticonvulsant Ø clonidine, beta blockers, buspirone Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 81

Strategies for Refractory Anxiety Disorder Ø Ø Maximize dose Combine antidepressant and benzodiazepine Administer cognitive-behavioral therapy Attend to psychosocial issues . Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 82

Strategies for Refractory Anxiety Disorders Ø Augmentation Ø Combined SSRI/TCA Ø Anticonvulsants Ø Alternative antidepressant Ø Gabapentin Ø Clomipramine Ø Valproate Ø MAOI Ø Topiramate Ø Other Ø Beta blocker Ø Inositol Ø Buspirone Ø Atypical neuroleptics Ø Clonidine/Guanfacine Ø Pindolol -nonselective beta blocker Ø Dopaminergic agonists for social phobia (pergolide) Ø Cyproheptadine Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 83

Questio n Tirat Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 87

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Trauma- and Stressor-Related Disorders New chapter in DSM-5 brings together anxiety disorders that are preceded by a distressing or traumatic event 1. 2. 3. 4. 5. Reactive Attachment Disorder Disinhibited Social Engagement Disorder (new) PTSD (includes PTSD for children 6 years and younger) Acute Stress Disorder Adjustment Disorders

Trauma- and Stressor-Related Disorders Acute Stress Disorder A. PTSD A Criterion B. No mandatory (e. g. , dissociative, etc. ) symptoms from any cluster C. Nine (or more) of the following (with onset or exacerbation after the traumatic event): 1. Intrusion (4) 2. Negative Mood (1) 3. Dissociative (2) 4. Avoidance (2) 5. Arousal (5)

Trauma- and Stressor-Related Disorders Adjustment Disorders -DSM-5 Adjustment Disorders are redefined as an array of stressresponse syndromes occurring after exposure to a distressing event. Adjustment Disorder subtypes are unchanged - with depressed mood - with anxiety - with disturbance of conduct

Chronic Adjustment Disorder Ø Omitted by mistake from DSM-5 Ø Acute AD – less than 6 months Ø Chronic AD –cannot persist more than 6 months after termination of stressor or its consequences

Other Specified Trauma/Stressor-Related Disorder (309. 89) AD with duration more than 6 months without prolonged duration of stressor Ø subthreshold PTSD Ø persistent complex bereavement disorder Ø ataques nervios and other cultural symptoms

Reactive Attachment Disorder Emotionally withdrawn behavior Ø Social/emotional disturbance - reduced responsiveness, limited affect &/or irritability, sadness or fearfulness Ø Exposure to extremes of insufficient care - social neglect/deprivation, repeated changes in caregivers, rearing in unusual settings Ø

Persistent Complex Bereavement Disorder Ø Ø Ø Ø Onset > 12 months after death of loved one Yearning/Sorrow/Pre-occupation with deceased Reactive distress to the death Social/Identity disruption Significant distress or impairment Out of proportion to cultural norms Traumatic specifier

Persistent Complex Bereavement Disorder (PCBD) Diagnostic Criteria-ICD A. B. 1. The person experienced the death of a close relative or friend at least 12 months ago. In the case of children, the death may have occurred 6 months prior to diagnosis. Since the death, at least one of the following symptoms is experienced on more days than not and to a clinically significant degree: Persistent yearning/longing for the deceased. In young children, yearning may be expressed in play and behavior, including separation-reunion behavior with caregivers. 2. Intense sorrow and emotional pain because of the death. 3. Preoccupation with the deceased person.

Persistent Complex Bereavement Disorder (PCBD) 4. c) Preoccupation with the circumstances of the death. In children, this preoccupation with the deceased may be expressed through themes of play and behavior and may extend to preoccupation with possible death of others close to them. Since the death, at least six of the following symptoms (from either reactive distress or social/identity disruption) are experienced on more days than not and to a clinically significant degree:

Reactive Distress to the Death 1. Marked difficulty accepting the death. In children, this is dependent on the child’s capacity to comprehend the meaning and permanence of death. 2. Feeling shocked, stunned, or emotionally numb over the loss. 3. Difficulty with positive reminiscing about the deceased. 4. Bitterness or anger related to the loss. 5. 6. Maladaptive appraisals about oneself in relation to the deceased or the death (e. g. , self-blame). Excessive avoidance of reminders of the loss (e. g. , avoidance of people, places, or situations associated with the deceased; in children, this may include avoidance of thoughts and feelings regarding the deceased).

Social/Identity Disruption 7. A desire to die in order to be with the deceased. 8. Difficulty trusting other people since the death. 9. Feeling alone or detached from other people since the death. 10. 11. 12. D. E. Feeling that life is meaningless or empty without the deceased or the belief that one cannot function without the deceased. Confusion about one’s role in life or a diminished sense of one’s identity (e. g. , feeling that a part of oneself died with the deceased). Difficulty or reluctance to pursue interests since the loss or to plan for the future (e. g. , friendships, activities). The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The bereavement reaction must be out of proportion or inconsistent with cultural, religious, or age-appropriate norms.

Ø Ø Specify if: With Traumatic Bereavement: Following a death that occurred under traumatic circumstances (e. g. homicide, suicide, disaster, or accident), there are persistent, frequent distressing thoughts, images, or feelings related to traumatic features of the death (e. g. , the deceased’s degree of suffering, gruesome injury, blame of self or others for the death), including in response to reminders of the loss.

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Trauma- and Stressor-Related Disorders Changes in PTSD Criteria Four symptom clusters, rather than three -Re-experiencing -Avoidance -Persistent negative alterations in mood and cognition -Arousal: describes behavioral symptoms

Trauma- and Stressor-Related Disorders Changes in PTSD Criteria DSM-5 more clearly defines what constitutes a traumatic event Sexual assault is specifically included Recurring exposure, that could apply to first responders

Trauma- and Stressor-Related Disorders Changes in PTSD Criteria Recognition of PTSD in Young children Developmentally sensitive: Criteria have been modified for children age 6 and younger Thresholds – number of symptoms in each cluster - have been lowered

DSM-5: PTSD Criterion A A. The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: 1. Direct exposure 2. Witnessing, in person

Criterion A (continued): Ø Ø 3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental. 4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e. g. , first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect nonprofessional exposure through electronic media, television, movies or pictures.

CRITERION B - Intrusion (5 Sx – Need 1) 1. Recurrent, involuntary and intrusive recollections * * children may express this symptom in repetitive play 2. Traumatic nightmares * children may have disturbing dreams without content related to trauma 3. Dissociative reactions (e. g. flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness * * children may re-enact the event in play 4. 5. Intense or prolonged distress after exposure to traumatic reminders Marked physiological reactivity after exposure to trauma-related stimuli

C. Persistent effortful avoidance of distressing traumarelated stimuli after the event (1/2 symptoms needed): 1. 2. Trauma-related thoughts or feelings Trauma-related external reminders (e. g. people, places, conversations, activities, objects or situations)

CRITERION D – negative alterations in cognition & Mood (7 Sx – Need 2) 1. 2. 3. 4. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs) Persistent (& often distorted) negative beliefs and expectations about oneself or the world (e. g. “I am bad, ” “the world is completely dangerous”) Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences (new) Persistent negative trauma-related emotions (e. g. fear, horror, anger, guilt, or shame) (new) 5. Markedly diminished interest in (pre-traumatic) significant activities 6. Feeling alienated from others (e. g. detachment or estrangement) 7. Constricted affect: persistent inability to experience positive emotions

CRITERION E – Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event (2/6 symptoms) 1. 2. 3. 4. 5. 6. Irritable or aggressive behavior Self-destructive or reckless behavior (new) Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance

PTSD Criteria for DSM-5 F. Persistence of symptoms (in Criteria B, C, D and E) for more than one month G. Significant symptom-related distress or functional impairment H. Not due to medication, substance or illness

Preschool Subtype: 6 Years or Younger Relative to broader diagnosis for adults (or those over 6 years): • Criterion B – no change (1 Sx needed) • 1 Sx from EITHER Criterion C or D - C cluster – no change (2 Avoidance Sx) - D cluster – 4/7 adult Sx ü Preschool does not include: amnesia; foreshortened future; persistent blame of self or others • Criterion E – 5/6 adult Sx (2 Sx needed) ü Preschool does not include reckless behavior

A. In children (younger than 6 years), exposure to actual or threatened death, serious injury, or sexual violence, as follows: 1. 2. 3. Direct exposure Witnessing, in person, (especially as the event occurred to primary caregivers) Note: Witnessing does not include viewing events in electronic media, television, movies, or pictures. Indirect exposure, learning that a parent or caregiver was exposed

DSM-5: Preschool PTSD Criterion B B. Presence of one or more intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. 2. 3. 4. 5. Recurrent, involuntary, and intrusive distressing recollections (which may be expressed as play) Traumatic nightmares in which the content or affect is related to the traumatic event(s). Note: It’s not always possible to determine that the frightening content is related to the traumatic event. 3. Dissociative reactions (e. g. , flashbacks); such trauma-specific re-enactment may occur in play 4. Intense or prolonged distress after exposure to traumatic reminders 5. Marked physiological reactions after exposure to trauma-related stimuli

Preschool PTSD Criterion C One or more symptoms from either Criterion C or D below: C. Persistent effortful avoidance of trauma-related stimuli: 1. Avoidance of activities, places, or physical reminders 2. Avoidance of people, conversations, or interpersonal situations D. Persistent trauma-related negative alterations in cognitions and mood beginning or worsening after the traumatic event occurred, as evidenced by one or more of the following: 1. 2. Negative emotional states (e. g. , fear, guilt, sadness, shame, confusion) Diminished interest in significant activities, including constriction of play 3. Socially withdrawn behavior 4. Reduced expression of positive emotions

Preschool PTSD Criterion E E. Alterations in arousal and reactivity associated with the traumatic event, , as evidenced by two or more of the following: 1. Irritable behavior and angry outbursts (including extreme temper tantrums) 2. Hypervigilance 3. Exaggerated startle response 4. Problems with concentration 5. Sleep disturbance

Preschool PTSD for DSM-5 F. Duration (of Criteria B, C, D and E) is more than 1 month G. The symptoms causes clinically significant distress or impairment in relationships H. Symptoms are not attributable to a substance (e. g. , medication or alcohol) or medical condition

Summary: PTSD in DSM-5 Perhaps PTSD should be re-conceptualized as a spectrum disorder in which several distinct pathological posttraumatic phenotypes are distinguished symptomatically & psycho-biologically. If so, optimal treatment for one phenotype might not necessarily be the best treatment for another.

Dissociative Subtype of PTSD New subtype for both age groupings of PTSD diagnosis: 1. 2. 3. Meets PTSD diagnostic criteria Experiences additional high levels of depersonalization or derealization Dissociative symptoms are not related to substance use or other medical condition

specifiers Specify whether: With dissociative symptoms: The individual’s symptoms meet the criteria for PTSD, and in addition, in response to the stressor, the individual experiences persistent or recurring symptoms of either of the following: ■ ■ Depersonalization: Persistent or recurrent experiences of feeling detached from , and as if one was an outside observer of, one’s mental processes or body (e. g. , feeling as though one were in a dream; feeling sense of unreality of self or body or of time moving slowly). Derealization: Persistent or recurrent experiences of unreality of surroundings (e. g. , the world around the individual is experienced as unreal, dreamlike, distant or distorted). Note: To use this subtype, the dissociate symptoms must not be attributable to the physiological effects of a substance (e. g. , blackouts, behavior during intoxication) or other medical condition.

PTSD Epidemiology Ø Ø Ø 7 -9% of general population 60 -80% of trauma victims 30% of combat veterans 50 -80% of sexual assault victims Increased risk in women, younger people Risk increases with “dose” of trauma, lack of social support, pre-existing psychiatric disorder Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

Comorbidities Ø Ø Ø Depression Other anxiety disorders Substance use disorders Somatization Dissociative disorders Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

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Course Ø Ø Ø The symptoms and the relative predominance of re-experiencing, avoidance, and increased arousal symptoms may vary over time. Duration of symptoms also varies: Complete recovery occurs within 3 months after the trauma in approximately half of the cases. Others can have persisting symptoms for longer than 12 months after the trauma. Symptom reactivation may occur in response to reminders of the original trauma, life stressors, or new traumatic events.

Course Continued Ø Ø The severity, duration, and proximity of an individual’s exposure to a traumatic event are the most important factors affecting the likelihood of developing PTSD. Social supports, family history, childhood experiences, personality variables, and pre-existing mental disorders may influence the development of PTSD can also develop in individuals without any predisposing conditions, particularly if the stressor is extreme. The disorder may be especially severe or long lasting when the stressor is of human design (torture, rape).

Estimated Risk for Developing PTSD Based on Event Ø Rape (49%) Ø Severe beating or physical assault (31. 9%) Ø Other sexual assault (23. 7%) Ø Serious accident or injury (i. e. car or train accident) (16. 8%) Ø Shooting or stabbing (15. 4%) Ø Sudden, unexpected death of family member or friend (14. 3%) Ø Child’s life-threatening illness (10. 4%) Ø Witness to killing of serious injury (7. 3%) Ø Natural Disaster (3. 8%) www. ptsdalliance. org www. nimh. nih. gov/pulicat/reliving. cfm

Differential Diagnosis Differential diagnosis of the disorder or problem; that is, what other disorders or problems may account for some or all of the symptoms or features. PTSD is frequently co-morbid with other psychiatric disorders including: Ø Ø Anxiety disorders Ø Acute Stress Disorder Ø Obsessive compulsive disorder Ø Adjustment disorder Ø Depressive disorders Ø Substance Abuse disorders

Differences between Acute Stress Disorder Ø Ø In general, the symptoms of acute stress disorder must occur within four weeks of a traumatic event and come to an end within that four-week time period. If symptoms last longer than one month and follow other patterns common to PTSD, a person’s diagnosis may change from acute stress disorder to PTSD.

Differences between PTSD and Obsessive. Compulsive Disorder Ø Both have recurrent, intrusive thoughts as a symptom, but the types of thoughts are one way to distinguish these disorders. Thoughts present in obsessive-compulsive disorder do not usually relate to a past traumatic event. With PTSD, the thoughts are invariably connected to a past traumatic event.

Differences Between PTSD and Adjustment Disorder Ø PTSD symptoms can also seem similar to adjustment disorder because both are linked with anxiety that develops after exposure to a stressor. With PTSD, this stressor is a traumatic event. With adjustment disorder, the stressor does not have to be severe or outside the “normal” human experience.

Differences Between PTSD and Depression Ø Depression after trauma and PTSD both may present numbing and avoidance features, but depression would not induce hyperarousal or intrusive symptoms

? מי מיועד יותר עוצמה של סטרסור ( פתאומיות )לא צפוי חוסר יכולת לשלוט על מתרחש victimization -sexual as opposed to nonsexual אצל צעירם העדר מערכת תמיכה Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa Ø Ø Ø 143

An adult's risk for psychological distress will increase as the number of the following factors increases: Ø Ø Ø Female gender 40 to 60 years old Little previous experience or training relevant to coping with disaster Ethnic minority Low socioeconomic status Children present in the home Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 144

Ø Ø Ø For women, the presence of a spouse, especially if he is significantly distressed Psychiatric history Severe exposure to the disaster, especially injury, life threat, and extreme loss Living in a highly disrupted or traumatized community Secondary stress and resource loss Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 145

Treatment Ø Individual Therapy Ø Group Support (especially for Chronic PTSD) Ø Medication

Treatment Continued ■ For PTSD in children, adolescents, and geriatrics the Ø Acute PTSD - Stress debriefing and preferred treatment is psychotherapy Ø Severe Acute PTSD - Stress debriefing, medication, group and individual psychotherapy Ø Chronic PTSD - Stress debriefing, medication, group and individual psychotherapy

Treatment Continued Ø Ø Ø Exposure Therapy- Education about common reactions to trauma, breathing retraining, and repeated exposure to the past trauma in graduated doses. The goal is for the traumatic event to be remembered without anxiety or panic resulting. Cognitive Therapy- Separating the intrusive thoughts from the associated anxiety that they produce. Stress inoculation training- variant of exposure training teaches client to relax. Helps the client relax when thinking about traumatic event exposure by providing client a script.

Treatment Continued Ø Ø Ø “Cognitive Restructuring involved teaching and reinforcing selfmonitoring or thoughts and emotions, identifying automatic thoughts that accompany distressing emotions, learning about different types of cognitive distortions, and working to dispute the distressenhancing cognitions, with a particular focus on abuse-related cognitions, for which therapist remained alert during the personal experience work. ” “In summary for women who did not drop out, CBT treatment was highly effective for achieving remission of PTSD diagnosis, ameliorating PTSD symptom severity, and reducing trauma-related cognitive distortions, compared with a WL control Group. ” (Mc. Donagh, A. , Mc. Hugo, G. , Sengupta, A, Demment C. C. , et al. , (2005) Randomized Trial of Cognitive-Behavioral Therapy for Chronic Posttraumatic Stress Disorder in Adult Female Survivors of Childhood Sexual Abuse. Journal of Consulting and Clinical Psychology, 73, 515 -524. )

Medications ■ approved for the treatment of Anxiety Disorders including PTSD Ø SSRIs – Sertraline (Zoloft), Paroxetine (Paxil), Escitalorpram (Lexapro), Fluvoxamine (Luvox), Fluxetine (Prozac) Ø Affects the concentration and activity of the neurotransmitter serotonin Ø May reduce depression, intrusive and avoidant symptoms, anger, explosive outbursts, hyperarousal symptoms, and numbing Ø FDA approved for the treatment of Anxiety Disorders including PTSD

Medications Continued Ø Tricyclic Antidepressants- Clomiprimine (Anafranil), Doxepin (Sinequan) Nortriptyline (Aventyl), Amitriptyline (Elavil), Maprotiline (Ludiomil) Desipramine (Norpramin) Ø Affects concentration and activity of neurotransmitters serotonin and norepinephrine Ø Have been shown to reduce insomnia, dream disturbance, anxiety, guild, flashbacks, and depression

Treatment Ø With treatment, symptoms should improve after 3 months Ø In Chronic PTSD cases, 1 -2 years

Future Direction of Treatment Ø Noradrenergic Agents Ø Beta Blockers – Propranolol

PTSD - Treatment Ø שילוב של טיפול תרופתי בנוגדי דיכאון וחרדה Ø בפועל מגיעים לכל הספקטרום של התרופות Ø טיפול פסיכולוגי – CBT כיום מקובלת שיטת ה - PE עם תוצאות טובות מאוד. 751 Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa

PTSD Myths PTSD is a complex disorder that often is misunderstood. Not everyone who experiences a traumatic event will develop PTSD, but many people do. MYTH: PTSD only affects war veterans. FACT: Although PTSD does affect war veterans, PTSD can affect anyone. Almost 70 percent of Americans will be exposed to a traumatic event in their lifetime. Of those people, up to 20 percent will go on to develop PTSD. An estimated one out of 10 women will develop PTSD at sometime in their lives. Victims of trauma related to physical and sexual assault face the greatest risk of developing PTSD. Women are about twice as likely to develop PTSD as men, perhaps because women are more likely to experience trauma that involves these types of interpersonal violence, including rape and severe beatings. Victims of domestic violence and childhood abuse also are at tremendous risk for PTSD.

PTSD Myths Continued Ø MYTH: Ø People should be able to move on with their lives after a traumatic event. Those who can’t cope are weak. Ø FACT: Ø Many people who experience an extremely traumatic event go through an adjustment period following the experience. Most of these people are able to return to leading a normal life. However, the stress caused by trauma can affect all aspects of a person’s life, including mental, emotional and physical well-being. Research suggests that prolonged trauma may disrupt and alter brain chemistry. For some people, a traumatic event changes their views about themselves and the world around them. This may lead to the development of PTSD.

PTSD Myths Continued Ø Ø Ø MYTH: People suffer from PTSD right after they experience a traumatic event. FACT: PTSD symptoms usually develop within the first three months after trauma but may not appear until months or years have passed. These symptoms may continue for years following the trauma or, in some cases, symptoms may subside and reoccur later in life, which often is the case with victims of childhood abuse. Some people don't recognize that they have PTSD because they may not associate their current symptoms with past trauma. In domestic violence situations, the victim may not realize that their prolonged, constant exposure to abuse puts them at risk.

What is Prolonged Exposure? Ø PE is a type of CBT, which is designed to specifically target a number of trauma-related difficulties. Ø Results of several controlled studies have shown it significantly reduce PTSD and other symptoms such as anxiety and depression, particularly in women following sexual and nonsexual assault (Foa et al. , 1999). Ø Clients meet once a week with a therapist for 60 to 90 minutes. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 162

Treatment sessions include 1. education about common reactions to trauma 2. breathing retraining (or relaxation training) 3. prolonged (repeated) exposure to trauma memories 4. repeated in vivo (i. e. , in real life) exposure to non-dangerous situations that are avoided due to trauma-related fear. Ø Clients are encouraged to confront the memory of the trauma through repeatedly telling the story to therapist and to confront things in life that are avoiding because they are frightening (e. g. , driving in a car, walking on the street at night). Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 163

Ø Post-treatment data from a study conducted by Foa and colleagues (1999) comparing prolonged exposure (PE), stress inoculation training (SIT; another cognitive -behavioral therapy focusing on anxiety management techniques), and the combination of PE and SIT, to a waitlist control (WL). 96 sexual and non-sexual assault survivors with chronic PTSD Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 164

Combat Reaction Ø Combat stress reaction, better known as "Shell Shock" is the post traumatic reaction of a soldier to an event which happened while in active combat. Ø Between 10 and 15% (30%. . . or more) of all wounded soldiers during a war are combat reaction victims. Ø In Israel there are 4000 such victims. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 165

The Background of Combat Reaction Ø The transition from civilian life to military life is acute. Ø The soldier loses freedom of choice and mobility and he must submit to coercing commanding authorities. Ø In order to adapt to the military surroundings and to the accompanying unpleasant conditions, the soldier must find within himself and use coping and adjusting mechanism. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 166

Ø Ø In wartime, a new and even more acute transition is added - the transition from conditions of peace and security to conditions of war. This transition entails further conflicts which add to the emotional burden of the soldier. The danger of being wounded or even killed is clear and tangible and becomes a constant burden on his emotional state. This pressure brings with it a drive to leave the danger zone. 167

Ø On the other hand the soldier feels solidarity with his unit, pride and honor and a bond to his friends and commanding officers and a feeling of responsibility for their fate, all of which contribute to his drive to continue and fight. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 168

Risk Factors Ø Ø Ø Risk factors for Combat Reaction are all the factors that influence the incidence of post-traumatic reactions in general, plus: Physical fatigue Lack of sleep Prolonged physical exertion Conditions of hunger Heat or cold Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 169

Ø Enforced passivity. When the soldier is deprived of activity and is in a state of waiting Ø Decreased morale. Ø The degree of support the soldier receives in his unit Ø The degree of identification with the goal. Ø How much the soldier feels a part of the mission he is involved in? Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 170

PIE principles Ø Proximity - treat the casualties close to the front and within sound of the fighting Ø Immediacy - treat them without delay and not wait till the wounded were all dealt with Ø Expectancy - ensure that everyone had the expectation of their return to the front after a rest and replenishment Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 171

The US services now use the more recently developed BICEPS principles: Ø Ø Ø Brevity Immediacy Centrality or Contact Expectancy Proximity Simplicity Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 172

Treatment results Ø Ø Ø Data from the 1982 Lebanon war showed that with proximal treatment 90% of CSR casualties returned to their unit, usually within 72 hours. With rearward treatment only 40% returned to their unit. In Korea 85% of US battle fatigue casualties returned to duty within three days and 10% returned to limited duties after several weeks. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 173

Controversy Ø Throughout wars but notably during the Vietnam War there has been a conflict amongst doctors about sending distressed soldiers back to combat. Ø During the Vietnam War this reached a peak with much discussion about the ethics of this process. Ø Proponents of the PIES principles argue that it leads to a reduction of long-term disability Ø Opponents argue that combat stress reactions lead to longterm problems such as posttraumatic stress disorder. Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa 174

תסמונת שואה דור ראשון דור שני Maale Carmel Mental Health Center, Bruce Rappaport Medical Faculty, Technion, Haifa Ø Ø 175

TAKE HOME Re-experiencing Avoidance Hyperarousal Reminders Hyperarousal u ho t ve es si ru mar s t In ght ck Ni shba fla s ht g Ang ry Star outbur s tl Lack e respon ts s co ncen se tra Diso mnia tion Persistent negative alterations in mood and cognition THREE PRONGS OF PTSD

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